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Recurrent aphthous stomatitis — Clinical Guidelines

Overview

Recurrent aphthous stomatitis (RAS) is a common, painful condition characterized by recurrent oral ulcers of unknown etiology, potentially influenced by immune dysfunction, nutritional deficiencies, and stress 1 2 3.

Diagnosis

Clinical presentation of recurrent oral ulcers 1 2.

Screening for vitamin deficiencies (vitamin D, iron, vitamin B12) 1 5.

Assessment of oxidative stress markers (vitamin A, E, C, malondialdehyde levels) 6.

Evaluation of stressful life events using validated questionnaires 3.

Management

First-line treatments:

- Topical corticosteroids for rapid symptom relief 7. - Multivitamin supplementation (100% RDI of essential vitamins) without significant efficacy demonstrated 4.

Adjunctive treatments:

- Cyanocobalamin supplementation, even in patients with normal B12 levels, may improve ulcer healing 5. - Stress management and psychological support 3. - Conversion of aphthous ulcers to wounds with adherent coating agents for pain control 7.

Special Populations

Pregnancy: Limited evidence; multivitamin supplementation may be considered cautiously 4.

Pediatrics: Specific dosing and efficacy data lacking; general principles apply 4.

Elderly: Increased risk of vitamin deficiencies; regular screening recommended 1 5.

Comorbidities: Address underlying conditions like celiac disease or hematological disorders 7.

Key Recommendations

Screen for vitamin D, iron, and vitamin B12 deficiencies in patients with RAS (Evidence: Moderate 1 5).

Consider topical corticosteroids for symptomatic relief of RAS episodes (Evidence: Moderate 7).

Evaluate and manage stressful life events as they correlate with RAS onset (Evidence: Moderate 3).

Cyanocobalamin supplementation may be beneficial even in patients with normal B12 levels (Evidence: Weak 5).

Regular follow-up and reassessment of treatment efficacy are advised due to variable response to interventions (Evidence: Expert opinion).

References

1 Al-Amad SH, Hasan H. Vitamin D and hematinic deficiencies in patients with recurrent aphthous stomatitis. Clinical oral investigations 2020. link 2 Saikaly SK, Saikaly TS, Saikaly LE. Recurrent aphthous ulceration: a review of potential causes and novel treatments. The Journal of dermatological treatment 2018. link 3 Huling LB, Baccaglini L, Choquette L, Feinn RS, Lalla RV. Effect of stressful life events on the onset and duration of recurrent aphthous stomatitis. Journal of oral pathology & medicine : official publication of the International Association of Oral Pathologists and the American Academy of Oral Pathology 2012. link 4 Lalla RV, Choquette LE, Feinn RS, Zawistowski H, Latortue MC, Kelly ET et al.. Multivitamin therapy for recurrent aphthous stomatitis: a randomized, double-masked, placebo-controlled trial. Journal of the American Dental Association (1939) 2012. link 5 Gulcan E, Toker S, Hatipoğlu H, Gulcan A, Toker A. Cyanocobalamin may be beneficial in the treatment of recurrent aphthous ulcers even when vitamin B12 levels are normal. The American journal of the medical sciences 2008. link 6 Saral Y, Coskun BK, Ozturk P, Karatas F, Ayar A. Assessment of salivary and serum antioxidant vitamins and lipid peroxidation in patients with recurrent aphthous ulceration. The Tohoku journal of experimental medicine 2005. link 7 MacPhail L. Topical and systemic therapy for recurrent aphthous stomatitis. Seminars in cutaneous medicine and surgery 1997. link80020-x)

Recurrent aphthous stomatitis